Multimodal Interdisciplinary Management of Level III Renal Cell Carcinoma With Inferior Vena Cava Tumor Thrombus: The Role of Preoperative Embolization, Intracaval Balloon Control, and Radical Nephrectomy With Inferior Vena Cava Thrombectomy

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Renal cell carcinoma with tumor thrombus extending into the inferior vena cava (IVC) above the hepatic veins (Mayo level III) is among the most technically demanding scenarios in urooncological surgery. We describe the case of a previously healthy 59-year-old gentleman who presented with a large right renal mass and a 9 cm tumor thrombus extending from the right renal vein into the intrahepatic IVC. After multidisciplinary discussion, the patient underwent a combined urovascular procedure preceded by a same-day interventional radiology (IR) intervention comprising selective right renal artery embolization, embolization of the highly vascular caval tumor thrombus, and the placement of an accommodating intracaval balloon for suprahepatic vascular control. A rooftop incision was used for radical nephrectomy with IVC thrombectomy under triple-level caval control and contralateral renal vein control; intraoperative cavography by the IR team confirmed complete extraction of the thrombus and a patent IVC. Estimated blood loss was minimal, and no transfusion was required. The combination of preoperative selective embolization, intracaval balloon assistance, and intraoperative cavography may improve hemostatic control, reduce the risk of intraoperative tumor embolization, and provide a reproducible adjunct to conventional surgical thrombectomy for level III IVC tumor thrombi. Further prospective studies and larger case series are mandated to define the incremental benefit of each component.

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